In addition to the above provisions, should the facility close, by order of the Department of Social Services or change the use of its function, the above fee is further subject to the following refund schedule:

The resident or the resident's responsible person shall be entitled to a refund of processing fees in excess of five hundred dollars ($500) in accordance with all of the following:

1. A 100-percent refund if processing fees were paid within six months of notice of eviction.
2. A 75-percent refund if processing fees were paid more than six months but not more than 12 months before notice of eviction.
3. A 50-percent refund if processing fees were paid more than 12 months but not more than 18 months before notice of eviction.
4. A 25-percent refund if processing fees were paid more than 18 months but less than 25 months before notice of eviction.
5. The processing refund required by this subdivision shall be paid within 15 days of issuing the eviction notice.

GENERAL PROVISIONS

In this agreement the resident will be referred to as “resident;” whereas resident family members, responsible person or party, and/or conservator will be referred to as “responsible person” or “responsible party.” Facility or licensee, as written in this agreement, is the operator of the facility and referred to as “facility” or “licensee.” Facility may also include employees that render services for and on behalf of facility or licensee.

The following is known as the facility’s Admission Agreement (“agreement” or “contract” or “contract of admission”) and is a valid offer of services. This document and all documents attached or presented at the time of admission are required to be signed at the time of and condition of admission. A signature to this contract represents a mutual acceptance of the provisions contained in this contract and is legally binding upon both parties to perform its portion of the contract. This contract binds both parties to the terms and conditions contained within. Failure of either party to adhere to the terms and conditions may constitute breach of contract. In addition, no rights or duties contained within this contract can be assigned or transferred or delegated to other persons or parties.

A residential care facility for the elderly, licensed by the California Department of Social Services (Department) is not allowed to provide 24-hour skilled nursing care. Mom & Dad’s House does not and cannot provide “one-on-one care.” Mom & Dad’s House does not assign one caregiver to provide 24-hour escort, bedside care, or continuous observation. Under California Health & Safety Code 1569.1, this licensed facility is designed to provide a “humane approach to meeting the housing, social and services needs of older persons,” and to “provide a homelike environment for older persons with a variety of care needs.”

COMPLETE CONTRACT

This document contains the entire agreement and any discussions and/or oral or implied terms which are not included in this contract are excluded and are not considered to be part of this agreement. This is the entire agreement between both parties. Modifications and amendments to this agreement, including any exhibit or appendix, shall be enforceable only if they are in writing and are signed by authorized representatives of both parties.

1. FACILITY / LICENSEE INFORMATION

Mom & Dad’s House is a Residential Care Facility for the Elderly (RCFE), licensed by the State of California, Dept. of Social Services, Community Care Licensing. NOTE: A residential care facility for the elderly licensed by the California State Department of Social Services is not allowed to provide 24 hour skilled nursing care.

2. NON-DISCRIMINATION STATEMENT

Mom & Dad’s House management and staff will not discriminate against a person seeking admission or a resident based on sex, race, color, religion, national origin, marital status, registered domestic partner status, ancestry, actual or perceived sexual orientation, or actual or perceived gender identity.

Gender Identity means a person’s stated identification with a sex, regardless of whether the stated sex is consistent with the person’s physical appearance, surgical history, genitalia, legal sex, sex assigned at birth, or name and sex, as they appear in medical records, and regardless of any statement by any other person, including a family member, conservator, or legal representative, that is contrary. A person who lacks the ability to communicate gender identity retains the gender identity most recently expressed by that person.

Because of recently passed legislation, the facility is compelled to implement record keeping procedures to ensure it ascertains the client’s gender identity, correct name as indicated by the resident, and the use of the correct pronoun (he, she, his, her, etc) when referring to the resident. If resident wishes to decline to provide the information, that is a resident’s right to do so. However, because facility can be cited for not attempting to obtain such information, client is encouraged to provide:

Client’s gender identity    _______________________________________

Client’s correct name      _______________________________________

Client’s correct pronoun  _______________________________________

I choose to exercise my rights and refuse to disclose the above.

3. LGBT RESIDENT RIGHTS (ATTACHMENT # 1)

Mom & Dad’s House – Assisted living facility does not discriminate and does not permit discrimination, including, but not limited to, bullying, abuse, or harassment, on the basis of actual or perceived sexual orientation, gender identity, gender expression, of HIV status, or based on association with another individual on account of that individual’s actual or perceived sexual orientation, gender identity, gender expression, or HIV status. You may file a complaint with the Office of the Sate Long-Term Care Ombudsman 559-224-9106 if you believe that you have experienced this kind of discrimination.

The licensee/administrator is required to advise the resident or responsible person of, and provide a copy of, the as required by Health and Safety Code section 1439.51. Those resident rights are attached.

Resident or Responsible Party, please initial in the space to the left acknowledging that you have received a copy of Health and Safety Code section 1439.51, a copy of LGBT Resident Rights and that these rights have been explained to you. (Attachment # 1)

4. RESIDENT INFORMATION

Resident’s Name: _______________________________________________________

SSN (Voluntary): _______________________________________________________

NOTE: "Responsible person" means an individual or individuals, including a resident relative, responsible person or party, and/or conservator, health care surrogate decision maker, or placement agency, who assist the resident in placement or assume varying degrees of responsibility for the resident's well-being.

Resident Language(s) Read

Under a recent revision to the California Code of Regulations, the Department may seek from the facility “the language(s) read by each resident. DSS claims this information will be kept confidential. Please indicate the language(s) read by the resident:

5. RESIDENT REPRESENTATIVE’S INFORMATION:

Resident’s Representative (if not resident) ___________________________________

Relationship ___________________________________________________________

Address ______________________________________________________________

Phone Number _________________________________________________________

6. REFERRAL AGENCIES

This facility may work with public or private referral or resident placement agencies. This facility, if it accepts such a referral and accepts and retains a resident referred by one or more referral agencies, must pay a referral or finder’s fee to such agencies. If you have previously contacted an agency to assist you in finding a residential care facility for placement of the resident, please list here:

__________________________________ Date of initial contact _________________

__________________________________ Date of initial contact _________________

7. PLACEMENT HISTORY

Facility anticipates the ability to meet all of our residents’ needs as identified in the physician’s medical assessment and facility’s initial and ongoing appraisals. Facility asks the resident or resident’s representative to disclose past facility placements or admissions in other residential care facilities and the reason(s) for leaving, as facility wants to ensure this will be the last facility the resident will need. Resident may refuse to disclose this information, but in order to accommodate all resident service needs and to prevent a future move, the facility asks resident or resident’s representative to disclose:

I have not previously been admitted into or placed into residential care.

I have been in other residential care facilities and the reason(s) for moving or relocation is/was _______________________________________________________ ____________________________________________________________________

8. ASSESSMENT AND EVALUATION OF RESIDENT

The facility must, as required by state regulation, conduct a pre-admission appraisal of resident needs and services and the facility’s ability to meet those needs. This appraisal is conducted by the administrator or designee using the criteria found in state regulation sections 87458, 87459, 87461 and 87462. Reappraisals are conducted when there is a significant change in the resident’s condition according to the provisions found in state regulation section 87463, and annually if the resident has a physician diagnosis of dementia. This reappraisal involves the resident’s physician, family and facility staff.

9. FAILURE TO PROVIDE COMPLETE INFORMATION

Facility is required by state law and regulation to conduct a pre-admission appraisal and any needed reappraisal to determine the care to be provided to the resident. Facility and resident, and/or responsible party, must be forthright in providing all needed and necessary information to determine suitability for admission and retention in residential care. Any false or misleading information provided by the resident, responsible party, physician and/or personnel caring for resident, may void this contract, according to state contract law, and lead to relocation or eviction.

10. HEALTH CONDITIONS

This facility does not and cannot provide medical care and is licensed by the Department to meet resident’s need for care. Clients that need emergency or hospital inpatient care or skilled nursing care may not be allowed to return to the facility if the facility assesses a resident and documents the client has a medical need that cannot be cared for within the limits of its license. The facility will advise resident’s physician and responsible party of the inability to meet client needs in addition to seeking placement at a higher level of care, if and until, the resident qualifies for residential care.

11. MEDICAL CARE ASSESSMENTS AND MEDICAL PROVIDERS

Title 22 section 87705(c)(5) requires facility’s residents with a diagnosis of dementia, including Alzheimer’s disease, to have an annual medical assessment to ascertain the ongoing dementia care needs and, conversely, for facility to make needed changes in the resident’s ongoing dementia care and supervision.

It may be necessary for resident to be assessed by a healthcare professional at least once per year and more often if resident has had a significant change in resident’s condition. This is required by Title 22, Division 6, Chapter 8, Section 87705, Care of Persons with Dementia. The Department of Social Services may also require an assessment by a healthcare professional under Title 22, Division 6, Chapter 8, Section 87458. The cost of such assessments are the responsibility of the resident or resident representative.

Facility encourages ALL residents to have at least an annual checkup performed by their current healthcare professional for facility to continue meeting all residents’ needs for care, and for residents to have their current medications and physical needs evaluated to ensure their continuing wellbeing.

12. BLOOD PRESSURE / HEART RATE / WEIGHT MONITORING

If resident requires blood pressure or heart medications based upon vital sign readings resident must provide facility with equipment necessary for staff or resident to take vital sign readings, such as a blood pressure machine. Same parameters apply for weight monitoring.

Facility requests that any equipment furnished for such readings be in good working order. Resident may take own vital sign readings upon verification from resident’s physician of resident ability to do so.

13. DIABETICS

Facility may and can accept diabetic residents. However, facility staff is unable, by state regulation, to administer injectable medications including insulin. Resident’s physician must verify resident can “self-administer” injectable medications, and facility reserves the right to have physician verify resident’s ongoing ability to self-administer injectable medication. Should residents using or needing injectable medication lose the ability to self-administer injectable medication, it constitutes reason for relocation via eviction as facility would not be able to meet the resident’s need. Unless written exception is provided by California Department of Social Services.

14. BASIC SERVICES

To provide a safe and healthful living environment for all residents the following basic services are available. The services actually provided will be those the resident wants and those the resident needs, based on the individual’s pre-admission appraisal, and the needs and services plan. Subsequent resident appraisals may result in the need for additional basic services.

1. Care and supervision as defined in Health and Safety Code 1569.2; One-on-one care is not provided.
2. Monitoring and observation for changes in physical, mental, emotional, and social functioning.
3. Notification to resident’s family, physician, and other appropriate person/agency of resident’s needs.
4. Lodging. If admitted into a shared room the facility will adhere to California Health and Safety Code 1569.269(a)(19) allowing a resident: “To share a room with the resident’s spouse, domestic partner, or a person of resident’s choice when both spouses,

partners, or residents live in the same facility and consent to the arrangement.” In addition, Health and Safety Code 1569.269(a)(17): “To reasonable accommodation of resident preferences concerning room and roommate choices.” Facility will make every attempt to provide a compatible roommate but cannot accommodate all residents with roommates. In this case a private room may be more suitable.

5. Food Services:
1. Three nutritious daily meals and snacks.
2. Special diet, if prescribed by a physician.
6. Helping gain access to supportive services which may include:
1. Arrange medical and dental appointment
2. Other health care services
3. Transportation
4. Leisure Activités
5. Social and Counseling Services
7. Mom & Dad’s House will assist in making appointments and arrangements for transportation for the resident’s medical and dental needs.
1. Transportation: Mom & Dad’s House encourages the responsible person to transport the resident to medical and dental appointments.
2. If the responsible person is unavailable and resident is capable of transferring to and from a car with minimal assistance or they are pre-registered with Access Transportation services or any other wheel chair specialized transportation, with previous authorization, Mom & Dad’s House may coordinate transportation and provide provide a private companion for the resident under the following parameters:
1. Medical or Dental appointments is within an 8 mile radius.
2. A $______/hour fee will be charged.
3. A minimum of 4 hours is required.
4. Actual cost of transportation will be added. Example cost for Uber or Access Transportation.
5. If resident is not capable of making their own decisions, responsible party should be available via phone call to provide medical information and make medical decisions on behalf of the resident.
6. Private Companion will not make any medical decisions on behalf of the resident.
7. All transportation arrangements require a minimum of 48 hours notice and subject to transportation and caregiver availability.
3. In an urgent situation, medical transport will be called immediately. Resident or their insurance are responsible for the emergency medical transport charge and will be billed directly by the medical transport company.
4. Assistance with personal activities of daily living as follows:
1. Dressing
2. Eating (Including feeding assistance)
3. Toileting
4. Bathing

5. Grooming
6.  Mobility Tasks
7. Other Personal Care Needs: Housework, meals, laundry, taking medication, appropriate transportation, correspondence, telephone, and related tasks.

8. Basic hygiene items of general use such as soap and toilet paper, toothpaste, Kleenex, shampoo, etc. will be furnished, unless the resident wants to use or requires a specific brand that the facility does not normally purchase. Any item that is for personal use only, such as tooth brush, deodorant, razors, shaving items, etc. will be provided by each resident or responsible person.
9. Laundering of personal clothing. General laundry service (washing and drying of personal laundry. Excluding dry cleaning and ironing.
10. Clean bed and bath linens weekly, or as often as needed.
11. Cleaning of resident’s room.
12. Comfortable and suitable bed and bedroom furniture. The resident may provide his/her own furniture as long as the room will accommodate the items. Furniture should be of good quality and safe. Mom & Dad’s House reserves the right to reject furnishings if facility believes the furniture is not safe or in a state of repair. Mom & Dad’s House recommends to bring a NEW mattress for the use of the resident (If mattress and linens are brought by the resident or responsible party, they shall be brand new and unused, due to risk of infestation of bedbugs, scabies, etc. Facility regrets this requirement but believes the protection of its residents and staff is the highest priority for care and liability.
13. Assistance with taking prescribed and over the counter medication, in accordance with physician’s instructions unless prohibited by law or regulation, as allowed by Community Care Licensing.
14. Bedside care and tray service for minor temporary illness or recovery from surgery. Tray service during the temporary illness or recovery surgery is provided without charge for two days. After two days, a fee of $______ per day will apply.
15. Coordination and supervision of physical and occupational therapy through any necessary outside agencies.
16. Mom & Dad’s House provides access to facility phone for the purposes of making local phone calls and receiving phone calls. If resident lacks the mental and/or physical capacity to dial phone, facility will provide assistance.
17. Coordination of private telephone and cable TV hook-up and service (at resident’s expense).
18. To practice universal precautions, facility staff will use gloves when caring for all residents.
19. Arrangement optional filed trips, for an extra fee, for the utilization of available community resources as follows:

1. Libraries
2. Community Centers
3. Senior Centers

Subsequent resident appraisals may result in the need for additional basic services.

15. RATE FOR BASIC SERVICES AND PAYMENT PROVISIONS

The monthly rate for basic services is $_____ per month.

Resident or authorized representative understands that the stated monthly amount, on a daily pro-rated basis, is due and payable from the Date of Admission, not the Move In Date. In the event that the designated room is not ready for occupancy on this date, the pro-rated amount begins on the date the designated room is ready for occupancy.

1. Statements are sent 5 - 10 days before the 1st of the month, which will include the rate for basic services and a list of itemized optional services incurred by the resident. The monthly fee must be paid in advance beginning on the first of the month and due the first of every month thereafter.
2. If the basic monthly fee is not received within five days of the due date, a late fee of $_______ per day will be assessed for each day that the fee is not received.
3. If the fee is not received within 15 days of its due date, eviction procedures will begin.
4. Should the facility receive a returned check from the bank, there will be a $_____ charge to cover bank fees and special handling costs, plus $_____ per day until secured payment is obtained.
5. If the resident is away from the facility for hospitalization, vacation, temporary placement outside this facility, etc., the monthly rate continues. Individuals other than the resident must have the legal right to discharge as determined by the facility upon seeing legal documentation. Please note, 30 day notice is required to vacate the facility.
6. All financial transactions pertaining to basic and optional services will be documented on the resident’s individual file. A copy of the file will be provided upon request from the resident or resident’s representative.

The monthly cost is as follows:

1. Basic Service Rate:                 $
2. Cost of optional services         $
3. Hospice Fee                            $

TOTAL                     $

Method of payment accepted:

1. Preferred method: ACH Payment, directly through emailed invoice
2. Check. Should Mom & Dad's House receive a returned check from the bank, there will be a $_____ charge to cover bank fees and special handling costs.

Payment should be mailed to:

Mom & Dad’s House
12340 Seal Beach Blvd.
Suite B, Box # 401
Seal Beach, CA 90740

Pre-addressed envelopes available at Mom & Dad’s House.

Direct Deposit:

Wells Fargo Bank
Mom & Dad’s House
Account # 1561842566
Routing # 122 000247

3. Cash

The monthly fee is to be paid by ___________________________, on behalf of ________________________________________________.

Please do NOT leave or hand checks with staff.

16. PLANNED ABSENCES AND CONTINUATION OF AGREEMENT

Mom & Dad’s House requires at least a 72-hours notice of resident planned absences to allow facility to prepare medications or other items that may be required. Facility must report to the State resident death; serious injury; an incident that threatens the welfare, safety or health of the resident; or an unexplained absence of the resident. Please immediately report to Mom & Dad's House if any of the above occurs while resident is in the custody of family.

If the resident is away from the facility for hospitalization, vacation, temporary placement outside this facility, etc., the monthly rate continues. The facility will hold the room up to the last day of a paid month unless the facility is notified in writing of the resident’s discharge. Individuals other than the resident must have the legal right to discharge as determined by the facility upon seeing legal documentation.

If the resident does not return to the room after being away and by the next monthly fee due date, the facility will hold the room for seven days upon receipt of a week’s fee prorated on a daily basis. For each additional seven-day period, another week’s fee must be received. Failure to pay this fee by the due date may result in involuntary discharge from the facility. Title 22 section 87224 requires a 30-day notice of eviction for non-payment of fees.

17. RELEASE OF LIABILITY WHEN IN FAMILY CUSTODY

By signing this agreement, I absolve Mom & Dad's House of any liability that occurs when the resident is away from Mom & Dad's House for a visit, outing, doctor’s or similar medical appointment, day care, vacation, or similar event which requires the resident to be in the custody or care of someone other than facility staff.

18. FUNDING SOURCE

The resident has the right to refuse to disclose the monthly fee-funding source. To decline to disclose this information simply write, “refuse to disclose” in the blank below. My funding source for payment of the monthly fees is________________________ ____________________________________________________________.

The resident funding source:

Include SSI/SSP funds. (Voluntary Disclosure)

Does not include SSI/SSP funds. (Voluntary Disclosure)

Mom & Dad’s House does not accept SSI/SSP dependent residents, and cannot accept SSI/SSP beneficiary’s personal and incidental needs allowance to pay for basic services, including care and supervision. Facility does not accept voluntary contributions from others as payment. Failure to reveal to the facility the SSI status of the resident may void this contract.

19. RATE CHANGE

_____ Any change in basic rate or optional services will be preceded by in writing 90 (ninety) days notice stating the amount of the increase, the reason for the increase, and a general description of the additional costs. This does not apply to a rate increase due to change in level of care or condition change which may be implemented after providing a twobusiness day written notice, nor does it apply to optional services provided under a separate fee for service management with the resident.

_____ Written notice will be provided to the resident and responsible person, if any, within two business days of providing service at a new level of care that results in a rate increase. The notice will include a detailed explanation of the additional services provided at the new level of care. Any change in the residents condition is documented by facility and physician's assessment.

_____ Hospice/Palliative care is provided at Mom & Dad’s House when prescribed by a physician and requested by resident or responsible person. An additional charge of $______ per month on top of his/her monthly rate will be assessed by the facility when hospice/ palliative care is provided. This charge is separate from the charges of the Hospice /Palliative Agency, which are usually paid by Medicare.

20. ANNUAL DISCLOSURE OF AVERAGE MONTHLY RATE INCREASES

_____ Mom & Dad’s House average monthly rate increase, and the average percentage of increase for each of the previous 3 years is explained in chart below. This disclosure is updated by January 31 of each year.

Please expect a yearly rate increase on the anniversary of admission.

21. OPTIONAL SERVICES

Optional Services are those services provided by Mom & Dad’s House that are not included under basic services and have additional fees.

_____ Special Food Products - Special food items are those food items not ordinarily used by Mom & Dad's House and are purchased for an individual resident's use and consumption at the request of the resident. If requested, special food products purchased for an individual resident will be itemized on a monthly statement and charged at facility's cost [as allowed by Title 22 section 87464(e)(3)].

_____ Field Trips - Mom & Dad’s House has incorporated various field trips into our activity schedule, to ensure that our residents are engaged physically and mentally, and have a change of scenario once in a while that helps them cut the routine. These field trips vary from visits to the Senior Center for exercises, lunch, bingo, parties, movies, mall, church, city events like luncheons, etc. To be able to make these field trips happen, we need to staff properly, and plan ahead to coordinate all logistics. Mom & Dad’s House charges $______ per person per field trip, to cover the costs inherent to make these field trips happen. This charge is added into the monthly statement.
The field trips are voluntary, and because of the risks when taking our residents out of our home are higher, we require a signed waiver (Attachment # 2) to be able to take your loved one in our field trips, and acceptance in writing to take your loved one in field trips, and how many field trips do you approve per month.

If accepted, the number of field trips per month is _____.

____ Long Distance Phone Charges—If resident uses facility phone to make long distance phone calls, these calls are charged to the resident at the cost of the call. A copy of charges will be placed in the resident’s file and itemized on a monthly statement. Resident may install a private line in resident living area at resident expense. Resident or resident’s representative must pay all charges associated with installation and maintenance of the phone and phone line and pay all charges for usage.

22. THIRD PARTY SERVICES

Third party services are those not operated, provided or controlled by the Mom & Dad’s House . The fees will vary depending upon provider. The resident or responsible person will enter into a contract directly with the third party services provider. Third-party services include, but are not limited to:

These services may be arranged by Mom & Dad's House when requested by the resident or responsible person. Facility reserves the right to monitor and assess the quality of these services. Rates for third party services may increase without notice, and facility is not responsible for advising resident or responsible person of increases. Some third-party providers, if hired by the resident or responsible person, will be subject to the conditions listed under "Private Companion.”

23. PRIVATE COMPANION

1. Mom & Dad’s House - does not provide one on one care during the day or night. Situations arise when resident needs may require a private companion. If a resident requires constant direct supervision, Mom & Dad’s House can provide a private companion at an additional hourly fee ($_____/hour, if provided by the facility) , until condition has improved. Subject on staff availability.
2. Personal Care Attendants from outside agencies may be used if approved by the Administrator. The agency shall ensure a criminal clearance on all staff, health screening, appropriate insurance including liability and worker’s compensation, proof of appropriate employer tax obligations, including but not limited to withholding of state and federal taxes, payment of disability and unemployment insurance. All appropriate labor laws are to be followed and the Personal Care Attendant supervised by an agency administrator familiar with facility’s community operations. Agency should provide proof to all legal requirements upon request. Any fees incurred in obtaining the latter must be paid by resident or resident’s representative.
3. All Personal Care Attendants from outside agencies are to be fully trained in all legally required topics to be able to assist residents in an RCFE environment, prior to coming to Mom & Dad’s House to serve a resident. Facility does not provide this training.
4. Proof of training should be provided upon request.
5. Personal Care Attendants may not perform any act not allowed by regulation or law.
6. The Personal Care Attendant, if employed by an agency, is expected to notify his/her supervisor and community staff of any change in resident status.
7. The Personal Care Attendants, if employed by an agency, are not to provide care at any time to any other resident in the community.
8. It is the responsibility of the agency to ensure proper training of the Personal Care Attendant employed by the agency in emergency procedures such as fire evacuation, disaster preparedness, etc.
9. Resident or responsible person assumes full responsibility for the actions of a private companion.
10. The hiring of a private companion does not alleviate any additional levels of care fees as facility must provide all basic and optional services and must meet all resident service needs.
11. Resident or resident’s representative is liable for any theft and loss that may be caused by the private companion.
12. Any private companion found soliciting other residents for business, found to be on the premises without authorization, which “substitutes” for other private companions, will be barred from entering the property. A private companion is for resident only, and not allowed to switch to be a companion for any other facility resident.

24. HOUSE RULES / FACILITY POLICIES:

This Admission Agreement provides the resident and responsible person with a detailed list of house rules provided at the time of admission.

The following rules must be observed. Failure to comply, will be grounds for eviction.

1. Verbal or Physical abuse directed toward other residents or staff
2. Smoking in the facility is strictly forbidden due to the health and safety risks to other residents and to facility staff.
3. Use of profanity or offensive language
4. Purposeful destruction of facility property
5. Violent behavior
6. Harming or a threat to harm oneself or others
7. Health conditions, which require staffing level which, are not available in the facility
8. Family/visitors which are abusive or upset the general resident population
9. Refusal to practice general hygiene techniques such as frequent bathing, oral care, clean clothing etc.
10. Refusal to store prescribed and over-the-counter medication, nutritional supplements, cleaning products and disinfectants in a secured and locked central location to prevent medication errors or accidental wrong usage. Resident has a right to privacy and facility respects that right. However, having medications in resident room without a physician’s authorization may result in facility citations and fines by the Department.
11. Noncompliance with physician orders that would result in a threat to the safety or wellbeing of the general resident population, i.e. refusal to treat an infection.
12. No medication, vitamins or food shall be brought into Mom & Dad's House without staff knowledge
13. Report of any change in health status which would affect the other residents or staff
14. Resident theft of facility or other resident belongings. If resident family or visitors are witnessed stealing facility or other resident belongings, the resident will be held liable for any replacement expenses.
15. Possessing or threatening to use a firearm, sharp object or other items that may constitute a danger to staff and other residents.
16. Having alcohol or other intoxicating substances without the express permission of licensee.
17. In shared rooms, the resident must turn off any audible devices, including the television, cell phone, tabloid devices, etc. to prevent disturbing other residents. In private rooms, any auditory device must be maintained at a sound level that will not disturb other residents.
18. The facility may admit individuals whose gender identity or sexual orientation differs from most of the resident population. The facility does not tolerate discrimination by residents against other residents as this may violate the State’s protected civil rights that include sex, race, color, religion, national origin, marital status, registered domestic partner status, ancestry, actual or perceived sexual orientation, or actual or perceived gender identity.

19. Resident’s bed, at resident option, may be pushed up against a wall in the room if the resident has a clear path and ability to get out of bed without obstruction.
20. Facility asks its residents and residents’ visitors to avoid overt displays of affection in public and common areas of the facility. Facility requests any sexual activities take place in residents’ rooms only. Residents in shared rooms must be respectful of a roommate if and when engaging in consensual sexual activities. Facility will attempt to assist with privacy in shared rooms if roommates are not consenting to sexual relations with each other.
21. Family members must notify in advance when they are going to take a resident out. We need to know what day and the approximate time you will be picking the resident up and how long they will be gone so we can prepare their medications.
22. Sign in / Sign Out
1. Residents are asked to check out when leaving Mom & Dad's House. The person accompanying the resident should do QR code screening prior to taking resident out. Residents may not be required to disclose their destination. However, for safety purposes the resident’s destination may be recorded if it is voluntarily disclosed.
2. Residents leaving for extended periods should notify the administrator in advance.
3. If residents are out during meal time, it is requested that staff be notified that the resident will be out.
4. Upon returning to Mom & Dad's House, resident or staff may sign them in.

When a resident is first placed in the facility it is particularly important that they be giving time to adjust without interference, let them know the day(s) and time you will be coming to visit.

The facility hereby believes these house rules/general policies are reasonable and necessary. The resident has the right under California State Health and Safety Code 1569.885 to suggest changes to these policies.

25. PROCEDURE FOR SUGGESTING HOUSE RULE CHANGES

Facility rules may be changed upon suggestions from the resident. AlI resident suggestions must be in writing and presented to the Administrator. The Administrator will review written suggestions within five working days of receipt. In considering policy changes Administrator will present suggested changes to the resident council (if one has been established) to ensure no resident right is violated or resident safety is compromised if a change occurs. After the review of written suggestions, Administrator will render a decision in writing to the person who submitted the suggestion.

26. FACILITY VISITING POLICY:

Mom & Dad's House encourages regular visits from family, friends and clergy.

1. Visiting hours at Mom & Dad’s House are from 10:00 AM to 7:00 PM every day including holidays.
2. Should you require other visiting times, please contact the administrator for advance arrangements
3. All visitors are required to sign in via QR code on a smartphone and complete a COVID screening questionnaire prior to entering the facility. If the visitor does not have a smart phone device, facility staff can provide a smart tablet to complete sign in.
4. After the COVID questionnaire is complete a green or red color screen will appear indicating completion. This is to be shown to the caregiver on duty where they will allow or deny entry.
5. Visitors are not allowed in shared rooms.
6. Mom & Dad’s House requests visitors and families to respect the rights of other residents and not to interfere with any patterns of resident’s established activities.
7. Visitors are asked to be dressed appropriately and to not smoke in facility. Facility prohibits visitors from bringing in cigarettes or cigars, lighters, matches, guns, knives or other sharp objects, medications, or money that have not been approved by the administrator.
8. Visitors are welcome to have meals with the resident as long as they notify caregivers at least 1 hour before the meal of their intention to stay for breakfast, lunch or dinner.
9. Residents can be reached on the phone from 8:00 AM to 7:00 PM. Phone calls can be made to Mom & Dad's House’s number (562) 354-6977, in which case the cordless phone is taken to the resident.
10. Mom & Dad’s House will periodically provide resident and resident’s representative with notices of facility activities and events. The resident’s representative is encouraged to participate.
11. We suggest that all mail is sent directly to the responsible party’s address, to avoid delay in getting any important documents.

Mom & Dad’s House - Assisted living facility will ensure that all communications to the facility from family and responsible persons answered promptly and appropriately. We will encourage regular family involvement with the resident and shall provide ample opportunities for family participation at the facility. Visitors, including ombudspersons and advocacy representatives, are permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.

Resident shall have reasonable access to telephones, to both make and receive confidential calls. The facility does require reimbursement for long distance calls. Resident will also be able to mail and receive unopened correspondence in a prompt manner.

27. GRIEVANCES / COMPLAINTS:

At Mom & Dad’s House we want to be sure that you are satisfied with the care that you receive from us. Please let us know right away if there is a problem or concern about any aspect of our service.

As a Mom & Dad’s House resident you have the right to file a grievance about anything you are not satisfied with regarding our service.

Here are a few examples:

1. The quality of services you receive in the home
2. Mistakes you feel have been made.
3. Behavior of any of your care providers or program staff.
4. Adequacy of our home facility.
5. Quality of food provided.

If you file a grievance, you will continue to receive services the same as before you filed the grievance. Mom & Dad's House employees will not discuss your grievance with other participants or anyone else not involved with investigating your grievance.

You may file a grievance with the administrator at (949) 381 - 1792, either verbally or in writing, at any time regarding facility’s general policies. The Administrator will review the grievance within five working days of its receipt with the resident council (if facility has one) and render a decision to the individual filing the grievance. We will continue to furnish you with all services at the frequency provided in the current plan of care during the grievance process.

It is the responsibility of the administrator to investigate and seek a resolution of the grievance, as soon as possible. All efforts will be made by the team to pursue a resolution to its outmost ability, so that problems with service delivery do not go unresolved. If you or your family member is still not satisfied with the resolution proposed by the team, you will be informed, either orally or in writing, of what action you may take.

The resident or resident’s representative has the right to file a grievance with Community Care Licensing or the State Ombudsman, or both, to resolve any complaints regarding facility practices. The ombudsman is intended as a resource for both of the following accessing additional information regarding resident care at the facility and for reporting resident care complaints. The following information is also contained on the resident’s (personal) rights form.

Under Health and Safety Code 1569.885, the following information is required in this admission agreement:

1. The telephone number of Community Care Licensing is (323) 980-4934.
2. It’s current website is https://cdss.ca.gov/inforesources/community-care-licensing.
3. The Long-Term Ombudsman’s telephone number is (562) 925-2346. In addition, a confidential complaint may be filed by calling (844) 538-8766 or by Email help@coasc.org.

4. The State’s Long-Term Ombudsman’s current website is https://aging.ca.gov/ Programs_and_Services/Long-Term_Care_Ombudsman/
5. To find the county’s Long-Term Care Ombudsman’s email address, go to https:// aging.ca.gov/Contact_Us/.

The resident has the right to present grievances and recommend changes in policies, procedures, and services to the staff of the facility, the facility’s management and governing authority, and to any other person without restraint, coercion, discrimination, reprisal, or other retaliatory actions. The licensee will take prompt actions to respond to residents’ grievances.

No officer or employee of Mom & Dad’s House by law (AB581), will discriminate or retaliate in any manner, including, but not limited to, eviction or threat of eviction, against any person receiving the services of the licensee’s residential care facility for the elderly, or against any employee of the licensee’s facility, on the basis, or for the reason that, the person or employee or any other person has initiated or participated in the filing of a complaint, grievance, or a request for inspection with the department pursuant to this chapter, or has initiated or participated in the filing of a complaint, grievance, or request for investigation with the appropriate local ombudsman, or with the state ombudsman.

28. ABUSE REPORTING

The personal rights form provided to the resident and the resident’s representative provides information about procedures for reporting known or suspected elder abuse, including the tollfree telephone number of the State Long-Term Care Ombudsman's CRISISline and the telephone number of the nearest approved organization for long-term care ombudsperson activities.

29. LICENSING REPORTS

Licensing reports are available for review at Mom & Dad's House, and copies of licensing reports and other documents pertaining to Mom & Dad's House are available from the district office of the Department of Social Services.

30. DEPARTMENT OF SOCIAL SERVICES RIGHTS TO ACCESS RECORDS:

The facility must allow the Department to review resident records kept by the facility. However, under H&S Code 1569.269(a)(3) resident must consent to the release of personal and private information and may legally refuse this inspection. Please indicate which resident right will be exercised. Either consent may be withdrawn at any time in writing by resident or resident’s representative.

I authorize the Department to inspect my personal records kept by the facility.

I do not authorize the Department to inspect my personal records kept by the facility.

31. LEGAL DOCUMENTATION

Mom & Dad's House must have copies of all legal documents, which allow someone other than the resident to make decisions regarding health and finances. These documents include, but are not limited to, Durable Powers of Attorney for Health Care, and Financial.

32. RESIDENT PERSONAL RIGHTS:

Any person admitted to the facility must be advised of his/her personal rights specified by law.

The resident and the resident’s representative, if any, is entitled under California State law to receive a copy of the resident’s personal rights pertaining to admission and retention in this facility. Under Health and Safety Code 1569.889, the personal rights form must contain the Ombudsman’s phone number. The form, produced by the Department, is LIC613C-2, and is provided to residents and responsible parties at the time of admission. I have received a copy. Under Title 22, Division 6, Chapter 8, Section 87468.2(f), the Department of Social Services does not have the authority to waive the personal rights in this regulation section.

33. HOSPICE / PALLIATIVE AND HOME HEALTH

If resident is recommended by a physician to be placed on hospice for a terminal illness as certified by two physicians, Mom & Dad’s House will adhere to Title 22 sections 87632 and 87633 and ask resident and/or responsible person to submit a written request to facility to be placed on hospice while residing in the facility. Mom & Dad’s House must approve the written request for retention and approve all hospice care plans prior to the initiation of hospice services by an outside agency. Mom & Dad’s House has worked with many hospice agencies in the community and may refer or recommend resident to agencies trusted by Mom & Dad’s House. Mom & Dad’s House reserves the right to reject the hospice agency selected by the resident or responsible party if facility has had trouble with that agency in the past. Mom & Dad’s House requires resident and/or responsible party to inform facility when client may be placed on hospice, so all the requirements of the state can be met, and facility may evaluate the services hospice agency claims to provide. If services and communications from agency are not to the level expected by Mom & Dad’s House, facility has the right to request change of provider.

Consent for Hospice Care and Facility Retention

Should I require hospice services, this agreement hereby acts as my request to receive hospice care and to be retained in the facility while receiving such care. I understand the facility may be required to deny this request if my condition has progressed to a condition not allowed in a residential care facility [Title 22, Section 87724(i)], if the facility’s hospice waiver capacity is at a maximum, or if roommate, if any, withdraws consent to any shared living space [Title 22, Section 87633(h)(5)(A)].

Roommate Consent for Hospice

Should resident occupy a shared room and the roommate requires hospice care, by signing below, resident consents to allow hospice into the shared living space. This consent may be withdrawn verbally or in writing by resident and/or resident’s responsible party.

Sharing of Resident Information—Home Health and Hospice

Should resident require any health care services provided by a home health or hospice agency, resident hereby agrees to release all written information provided by the home health or hospice agency to the facility to ensure that the resident’s care needs can be met by the facility, and to prevent any prohibited conditions from developing.

34. PERSONAL PROPERTY / THEFT AND LOSS PROGRAM: (ATTACHMENT # 3)

_______ I have received a copy of LIC 621 Personal Property/Valuables Entrusted to Facility.

Resident or Responsible Party, please initial in the space to the left acknowledging that you have received a copy of Health and Safety Code Sections 1569.74, 1569.152, 1569.153, 1569.154. and Title 22 Section 87218 and an explanation and a copy of the facilities Personal Property Theft & Loss Program. Resident or Responsible Party, please initial in the appropriate space below:

_________ I agree to have my clothing inventoried per the facility theft & loss policy.

_________ I opt NOT to have my clothing inventoried.

However, California Health and Safety Code 1569. 153(d) and Title 22 Section 87218(a) (1) mandates that other personal property items be inventoried at the time of admission and as brought into the facility after admission.

All items must be requested in writing to be added to or deleted from the Personal Property Inventory List, as mandated by California State Health and Safety Code 1569.153(d). Responsible person is asked to assist facility in marking all resident items for identification purposes.

1. Residents are encouraged to keep no more than $______ cash at any time.
2. Residents should keep fine jewelry and other items of value in a safe deposit box at their banking institution.
3. No items of value will be entrusted to Mom & Dad's House for safe keeping and no cash or other moneys will be entrusted to Mom & Dad's House.
4. Mom & Dad's House does not have a safe on the premises to allow for safe keeping of residents’ valuables. Residents are encouraged to use their own private banking institution to provide this service.

I have received a copy of this policy and procedure, which includes California State Health and Safety Codes 1569.152 - .154. . (Attachment # 3)

35. BREAKAGE / DAMAGE FEE

The facility is not allowed to collect a deposit against possible damages caused by the resident. There is no prohibition in Title 22 or Health and Safety Code for charging the resident or responsible person for damages that may be caused by the resident. This includes breakage of facility property, blocking of toilets or plumbing by placing inappropriate items into plumbing fixtures (i.e. clothing, adult briefs, etc.), and the soiling of facility carpeting. The facility will not attempt to collect a fee for normal wear and tear caused by the resident, and any suspected damage or breakage will be discussed with resident or responsible person. Any amount billed for damages will be the actual cost of replacement or repair.

36. RENTER’S INSURANCE

Mom & Dad’s House does NOT charge rent or refer to its service fees as “rent.” This facility is NOT governed by Fair Employment and Housing. California Health and Safety Code 1569.147 states facilities are not under any form of rent control.

However, Mom & Dad’s House strongly recommends that resident obtain renter’s insurance that can be obtained through most insurance companies. Renter’s insurance protects resident’s clothes, electronics, furniture, prosthetic devices, etc., should these be lost or damaged, or even stolen. Facility’s insurance does not cover resident’s personal belongings.

37. HOARDING

Hoarding is defined as “the persistent difficulty discarding or parting with possessions, regardless of their actual value.” Mom & Dad’s House has specific fire clearance requirements and is unable to allow residents to “hoard” items that may block exits and passageways, or to take up space used for necessary personal items. Resident is not allowed to hoard disposable items such as newspapers, magazines, shopping bags or anything else determined by the facility administrator or staff to be a fire, tripping or other hazard. Mom & Dad’s House does not “store” resident items that are not related to resident personal care or necessary for resident physical needs. Facility will discuss this issue with resident and/or representative.

38. TELEPHONE SERVICES

A central telephone is available for all residents. Local calls may be made at no charge. Long distance calls will be billed to the resident monthly at the actual cost of the call as outlined on the telephone bill.

The licensee/administrator is required to advise the resident or responsible person of, and provide a copy of a Telecommunication Device Form (LIC 9158) for each resident

whose pre-admission appraisal or medical assessment indicates he/she is deaf, hearing-impaired, or otherwise disabled.

I have received the Tele-communications Device Notification Form.

39. ADVANCE HEALTH CARE DIRECTIVE:

I have received a copy of the State’s brochure:
“Your Right to Make Decisions About Medical Treatment.” (Attachment # 4)

Mom & Dad's House must provide the resident or responsible person with the information contained in Title 22 section 87575.1(b) and (c), which is hereby presented:

Facility advises resident and representative to have a completed Do-Not-Resuscitate (DNR) or Physician Orders for Life-Sustaining Treatment (POLST) on file with facility and obtained prior to or within two weeks of admission.

To comply with state regulations, the facility must provide the resident or resident’s representative with the following information contained in Title 22 section 87469 (b), (c), and (d):

87469(b): Residents shall be permitted to have a Request Regarding Resuscitative Measures form on file, which can include Physician Orders for Life Sustaining Treatment (POLST) and/or a Do-Not-Resuscitate (DNR) Form in their facility file.

87469(c): If a resident who has a Request to Forego Resuscitative Measures, and/or an Advance Health Care Directive and/or a DNR form on file experiences a medical emergency, facility staff shall do one of the following:

1. Immediately telephone 9-1-1, present the Request to Forego Resuscitative Measures, Advance Health Care Directive and/or a DNR form to the responding emergency medical personnel and identify the resident as the person to whom the order refers.

OR

2. Immediately give the Request to Forego Resuscitative Measures, and/or Advance Health Care Directive and/or DNR form to a physician, registered nurse or licensed

vocational nurse if the physician or nurse is in the resident’s presence at the time of the emergency and assumes responsibility.

3. Specifically for a terminally ill resident that is receiving hospice services and has completed an advance directive and/or request regarding resuscitative measures form pursuant to Health and Safety Code section 1569.73(c), and is experiencing a lifethreatening emergency as displayed by symptoms of impending death that is directly related to the expected course of the resident’s terminal illness, the facility may immediately notify the resident’s hospice agency in lieu of calling emergency response (9-1-1). For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1).
4. Facilities that employ health care providers, other than Home Health Agencies or Hospice Agencies, may comply with Health and Safety Code section 1569.74. (Facility does not have such policies.)

87469(d) After following the procedure in Section 87469(c)(1), (2), (3), or (4), as outlined above, facility staff shall notify the resident's hospice agency and Health Care Surrogate Decision Maker, if applicable.

40. INFORMING EMERGENCY RESPONDERS

By state laws and regulations, the facility cannot make any other arrangements regarding the calling of 911 in case of resident emergency. If the resident is receiving hospice services from a licensed hospice agency, facility is allowed under Health and Safety Code 1569.73(c) to call the hospice first, not 911, if the resident experiences a life-threatening emergency related to the resident’s terminal illness.

Facility does not have a policy prohibiting any employee from voluntarily providing emergency medical services, including, but not limited to, CPR, in response to a medical emergency unless resident has expressed, in writing, a request regarding resuscitation, DNR or POLST form. In addition, facility may adopt or enforce a policy authorizing any employee trained in emergency services to provide those services to facility residents. Notwithstanding the above, any available facility employee may voluntarily provide emergency medical services if a trained and authorized employee is not immediately available or is otherwise unable or unwilling to provide emergency medical services.

41. CONSENT AND EMERGENCY ROOM (ER)

If resident is transported to the emergency room by ambulance or other means for an incident or 9-1-1 call, Mom & Dad’s House staff will provide the ER staff with resident’s personal information, insurance, POLST and/or DNR, and health condition (physician’s Report). Upon consent, facility will provide some information for emergency responders (see “consent” in this agreement). Facility is unable to go with the resident to the ER and sit and wait with the resident, and facility is unable to transport resident back to the facility. Responsible party is charged with arranging with the facility or others to return

the resident safely back to the facility, which may include non-medical transport companies. Facility will work with the family and the resident to insure a safe return. When a resident is transported to the ER, this represents a “transfer of care,” and the facility is not liable for any incidents that may occur to the resident at the time the client is transported away from the facility. Facility cannot provide an escort.

The signature(s) below give consent to the facility to release to emergency response personnel the following documents:

1. Emergency contact Information
2. List of Medications
3. Consent for medical treatment
4. Physician assessment/report
5. POLST / Do not resuscitate form (If applicable).

All other resident records are confidential and are not released to any party or agency without the express written consent of resident or responsible person.

42. EMERGENCIES / NATURAL DISASTERS

In case of an emergency where we have to evacuate Mom & Dad’s House on short notice, we require an Emergency Backpack for each resident. This backpack should be large enough to hold the main items required, but light enough that our ambulatory residents can carry it themselves and non-ambulatory can carry in their lap while in their wheel chair. This backpack should be labeled and provided to staff within the first week of admission.

Facility is prepared for but hopes that it will not be affected by a natural or man-made disaster. Facility cannot control the occurrences of earthquakes, floods, fires or other natural or manmade disasters (including terrorist incidents). Should a disaster occur, facility will implement its emergency disaster plan filed with the Department at the time of licensure. Such a plan is available to residents and their responsible parties. Facility cannot guarantee emergency authorities can reach facility or that facility has any priority with emergency agencies in the event of any disaster or emergency. Facility’s off-duty staff may not be able to reach the facility in case of an emergency or may be compelled to attend to their own family’s needs. Facility’s on-duty staff may also have to attend to family needs and may attempt to leave the facility. However, licensee will ensure all residents’ needs are met and supervision will be present 24- hours-per-day.

In addition, facility cannot guarantee it can evacuate the clients if roads, emergency authorities or other conditions prevent it. Facility will make every attempt to comply with Health and Safety Code 1569.695 in contacting emergency agencies, families,

hospice agencies (if necessary) and others to assist in evacuation should it become necessary to vacate its premises. Facility is required to be self-reliant for at least 72 hours but may not be able to sustain its operation if premises become uninhabitable or evacuation is ordered by emergency agencies.

Facility will seek the assistance of resident’s responsible party to assist in relocating and/or transporting the resident to temporary housing. Again, it is hoped that no emergency or disaster would necessitate evacuation, but recent events in our nation and around the world make it necessary to be prepared for any known disasters. Facility may and will seek the help of resident’s responsible parties to ensure the health and safety of the client in the event of an emergency.

Under Health and Safety Code 1569.695, revised for 2019 by the California State Legislature, facility is required to make every attempt and effort to communicate with resident’s representative during any emergency. Please provide facility with the best possible way(s) to reach resident’s representative during an emergency or disaster. This may include landline, cellphone, email, social media, text messaging, etc.:

_____________________________________________________________________

Out of state contact in case of an emergency:

_____________________________________________________________________

43. PERSONAL PROTECTIVE EQUIPMENT (PPE)

This facility is required to practice basic universal precautions as defined in Title 22 section 87101(u). This includes handwashing with soap and water, the wearing of non-sterile gloves, proper disposal of infectious materials and the cleaning with a bleach-based disinfectant. However, if ordered by the Center for Disease Control, World Health Organization, California Department of Public Health, Department of Social Services or other authoritative health organizations, facility may be forced to take more drastic measures to prevent the transmission of highly infectious diseases, i.e., COVID-19, HIV, SARS, flu of all types, H1N1, etc. Then, facility may have to invest in specialty personal protective equipment that is not part of its basic universal precautions’ protocols.

These can and may include the purchase of N95 facemasks (or similar), gowns, foot coverings or booties, high-alcohol hand sanitizers, and other items. Facility must pass on these added costs to residents and visitors and will do so at its cost. These will be itemized on resident statements.

44. DEMENTIA CARE:

Mom & Dad’s House provides environments, services and programs specific for dementia care and they are described in the facility’s Plan of Operation. Plan of Operation is available for review upon request. The facility does NOT have secured perimeters, thus Title 22 sections 87705(k)(l) do not apply.

45. MEDICATIONS:

1. Provision of medications

If resident’s representative does not purchase physician-prescribed medication for facility to assist in medication administration, facility is not responsible for obtaining or paying for resident medication as allowed and mandated under California and United States contract law provisions known as the Statute of Frauds. Facility is required by law to report the failure to provide medication to the physician, law enforcement, Adult Protective Services, the Ombudsman, and the Department of Social Services. The failure of a resident’s representative to provide medication may be prosecuted as elder abuse, a criminal offense in California. Facility is not legally required to obtain the medication as this would be in violation of Title 22 “Health Care Surrogate Decision Maker” provisions.

2. Over the counter medications

Title 22 regulation # 87465 requires that all prescription and nonprescription medications for which Mom & Dad’s House provides assistance must have a pharmacy label on the medication, as well as a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, containing the following information:

1. The specific symptoms which indicate the need for the use of the medication.
2. The exact dosage.
3. The minimum number of hours between doses.
4. The maximum number of doses allowed in each 24-hour period.
3. Crushing Medications

Should resident require medications to be crushed or altered (i.e., cutting), by signing below, resident or responsible party consents to allow facility to place medication(s) into food or other substances—called “hiding or camouflaging” by state regulation—to enhance taste or allow ease of swallowing. Facility may consult with pharmacy or resident physician to ensure that resident medications may be safely crushed or altered. This consent is required under Title 22, section 87465.

4. Disposal of medications after death of a resident

Upon death of a resident, Mom & Dad’s House will destroy all medications belonging to the deceased resident. No medication will be given to the POA, relative or friend.

5. Use of Medical Marihuana

Mom & Dad’s House does not allow the use of medical marijuana delivered via cigarette or other method of smoking or inhaling. Other forms of marijuana delivery may be allowed and must be discussed with the licensee prior to admission or prior to its usage. The facility does not allow the cultivation or growing of marijuana in the facility. Medical Marijuana will be treated by the facility like any other medication.

46. USE OF PHARMACY OUTSIDE FACILITY’S UNIFORM PACKAGING SYSTEM,   E-MAR & COMMUNICATION SYSTEM

Under California law a facility cannot require a resident “to purchase medications from any particular pharmacy.” However, this same law allows a facility to establish reasonable policies and procedures that are necessary to assist residents with the taking of their medications. The facility’s uniform packaging system, also known as “bubble packing,” and pre-packed system is a convenient and safer mechanism for the facility to manage a resident’s medications. It involves specialized packaging used by pharmacies to reduce medication errors and insures a reasonable assistance and assists facility in staying in compliance with state and federal laws and regulations.

Mom & Dad’s House preferred pharmacy also has an electronic medication management system that seamlessly integrates prescriptions and facilitates administration of medications.

If resident does not wish to use Mom & Dad’s House preferred pharmacy, the facility reserves the right to charge resident $______ per month. This charge is necessary as the facility must dedicate more time and efforts to safeguard medications, order medications, contact pharmacies, count medications, handwrite centrally stored sheets as required by the state, etc. Signing below acknowledges this extra charge IF the resident or responsible party opts out of facility’s Uniform Packaging System. This includes medications provided to the resident while in hospice care. Exceptions may apply for Care Packs or medications that preferred pharmacy may not provide in a timely manner.

47. CONDITIONS FOR EVICTION:

1. Three-day Eviction Notice

Mom & Dad’s House may give a 3-day written notice to evict, provided written approval is obtained from the Department of Social Services. The Department may grant approval for the eviction upon a finding of good cause. Good cause exists if the resident is engaging in behavior that is a threat to the mental and/or physical health or safety of himself or to the mental and/or physical health or safety of others in Mom & Dad's House. Copies of any notice of eviction will be sent to the resident, responsible person, Community Care Licensing and any placement agency.

California law requires specific information to be included within the notice of eviction (notice to quit), and facility will comply with all legal requirements.

In case of an eviction, the eviction notice will include the following information as required in SB 781:

1. The reasons relied upon for the eviction, with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. The effective date of the eviction.
2. Resources available to assist in identifying alternative housing and care options, including public and private referral services and case management organizations.
3. Information about the resident’s right to file a complaint with the department regarding the eviction, with the name, address, and telephone number of the nearest office of community care licensing and the State Ombudsman.
4. In order to evict a resident who remains in Mom & Dad's House after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge.
5. If Mom & Dad's House pursues the unlawful detainer action, resident will be served with a summons and complaint.
6. Resident have the right to contest the eviction in writing and through a hearing.

2. Sixty-day Eviction Notice

Mom & Dad’s House may evict the resident for one or more of the following reasons:

1. Nonpayment of the rate for basic services within 10 days of the due date.
2. Failure of the resident to comply with state or local law after receiving written notice of the alleged violation.
3. Failure of the resident to comply with written general policies of Mom & Dad's House. Said general policies must be in writing, must be for the purpose of making it possible for residents to live together and must be made part of the admission agreement.
4. If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87587, and the licensee and the person who performs the reappraisal believe that Mom & Dad's House is not appropriate for the resident.

5. In the event of a change of facility ownership or transfer of property or business.
6. Intent to sell
7. The licensee surrenders the license to the department.
8. Change of use of the facility.

Mom & Dad’s House will provide at least a 60-days written notice to resident, resident’s representative, and Community Care Licensing of the facility’s intent to evict.

3. Facility Responsibilities under Forfeiture of License or Change in Use of Facility

If the above, 60-day eviction does occur facility will take all reasonable steps to transfer affected residents safely and to minimize possible transfer trauma, and shall, at a minimum, do all of the following:

1. Prepare, for each resident, a relocation evaluation of the needs of that resident, which shall include both of the following:
1. Recommendations on the type of facility that would meet the needs of the resident based on the current service plan.
2. A list of facilities, within a 60-mile radius of the resident's current facility, that meet the resident's present needs.
2. Provide each resident or the resident’s representative with a written notice no later than 60 days before the intended eviction. The notice shall include all of the following:
1. The reason for the eviction, with specific facts to permit a determination of the date, place, witnesses, and circumstances concerning the reasons.
2. A copy of the resident's current service plan.
3. The relocation evaluation.
4. A list of referral agencies.
5. The right of the resident or resident’s representative to contact the department to investigate the reasons given for the eviction.
3. Discuss the relocation evaluation with the resident and his or her resident’s representative within 30 days of issuing the notice of eviction.
4. Any refund of pre-admission fees will be according to schedule found on pages 1 and 2 of this agreement.

Facility Responsibilities under Closure or Change of Use.

The facility is responsible for the following should eviction take place under closure or change of use provisions:

1. Submit a written report of any eviction to the licensing agency within five days.
2. Upon issuing the written notice of eviction, a licensee shall not accept new residents or enter into new admission agreements.
3. Refund any monies under the preadmission agreement terms found on pages 1 and 2, including payment of said fees within 15 days of issuing the eviction notice. In lieu of the refund, the resident may request that the licensee provide a credit toward the resident's monthly fee obligation in an amount equal to the preadmission fee refund due.

4. If the resident gives notice five days before leaving the facility, the licensee shall refund to the resident or his or her legal representative a proportional per diem amount of any
5. prepaid monthly fees at the time the resident leaves the facility, and the unit is vacated. Otherwise, the licensee shall pay the refund within seven days from the date that the resident leaves the facility, and the unit is vacated.
6. Within 10 days of all residents having left the facility, the licensee, based on information provided by the resident or resident's legal representative, shall submit a final list of names and new locations of all residents to the department and the local ombudsperson program.
7. If seven or more residents of a residential care facility for the elderly will be transferred because of the forfeiture of a license or change in the use of the facility, the licensee shall submit a proposed closure plan to the department for approval. The department shall approve or disapprove the closure plan, and monitor its implementation, in accordance with the following requirements:

1. Upon submission of the closure plan, the licensee shall be prohibited from accepting new residents and entering into new admission agreements for new residents.
2. The closure plan shall meet the requirements described in subdivision (a) and describe the staff available to assist in the transfers. The department's review shall include a determination as to whether the licensee's closure plan contains a I evaluation for each resident.
3. Within 15 working days of receipt, the department shall approve or disapprove the closure plan prepared pursuant to this subdivision, and, if the department approves the plan, it shall become effective upon the date the department grants its written approval of the plan.
4. If the department disapproves a closure plan, the licensee may resubmit an amended plan, which the department shall promptly either approve or disapprove, within 10 working days of receipt by the department of the amended plan. If the department fails to approve a closure plan, it shall inform the licensee, in writing, of the reasons for the disapproval of the plan.
5. If the department fails to act within 20 working days of receipt of the original or the amended closure plan, the plan, or amended plan, as the case may be, shall be deemed approved.
6. Until the department has approved a licensee's closure plan, the facility shall not issue a notice of transfer or require any resident to transfer.
7. Upon approval by the department, the licensee shall send a copy of the closure plan to the local ombudsperson program.
8. If a licensee fails to comply with the requirements of subdivision (a), and if the director determines that it is necessary to protect the residents of a facility from physical or mental abuse, abandonment, or any other substantial threat to health or safety, the department shall take any necessary action to minimize trauma for the residents. The department shall contact any local agency that may have placement or advocacy responsibility for the residents and shall work with

those agencies to locate alternative placement sites, contact relatives or other persons responsible for the care of these residents, provide onsite evaluation of the residents, and assist in the transfer of residents.

9. A resident of a residential care facility for the elderly covered under this section, may bring a civil action against any person, firm, partnership, or corporation who owns, operates, establishes, manages, conducts, or maintains a residential care facility for the elderly who violates the rights of a resident, as set forth in this section. Any person, firm, partnership, or corporation, who owns, operates, establishes, manages, conducts, or maintains a residential care facility for the elderly who violates this section shall be responsible for the acts of the facility's employees and shall be liable for costs and attorney fees. Any such residential care facility for the elderly may also be enjoined from permitting the violation to continue. The remedies specified in this section shall be in addition to any other remedy provided by law.

48. FAILURE TO PAY

Facility reserves all rights to collect any unpaid balances using all possible means. The resident or responsible person may be liable for all reasonable legal fees and costs of collection. Failure to pay also constitutes a breach of contract, and facility may seek in a court of equity payment under the terms of this contract.

49. RELOCATION AND APPEAL NOTICE:

No involuntary transfer, discharge, or eviction will take place without proper notice. In case of relocation ordered by DSS, residents may appeal the decision directly to Community Care Licensing. In case of discharge or eviction, resident may appeal first to the Administrator/ Licensee and if the resolution of the complaint is not acceptable, address the complaint to Community Care Licensing.

Mom & Dad’s House is offering relocation assistance by providing the resident and/or responsible person with a list of other facilities or placement agencies. H&S Code Section 1569.316 and 1569.47 discourage a facility from making a direct referral to another facility. It is the resident or responsible person’s responsibility to ensure the new facility can care for the resident within the confines of its license.

NOTE: When DSS orders relocation of a resident, due to a health condition that cannot be cared for within the limits of the licensee, the resident shall not be held responsible for meeting any advance notice requirement imposed by the licensee in the admission agreement. The licensee shall refund any money the resident would have been entitled had notice been given as required by the admission agreement.

Department Relocation

If a resident has a health condition which cannot be cared for within the limits of the license, requires inpatient care in a healthy facility, or has a health condition prohibited by Title 22 Sections 87582(c) or 87701, the Department may/shall order the licensee to

relocate the resident. In cases where the Department determines that the resident is in imminent danger because of a health condition(s) which cannot be cared for in Mom & Dad's House or which requires inpatient care in a licensed health facility, the department shall order the licensee to immediately relocate the resident.

50. REFUND POLICY

_____ The monthly fee paid in any given month will not be refunded in case of a temporary leave or in case of voluntary permanent departure, unless a written 30 days notice is given to the administrator, in that particular month, regardless of the reason.

_____ The total monthly rate set forth in the admission agreement will not be prorated on a daily basis upon the resident’s permanent departure from the facility during the month.

A prorated refund will be made, if requested, only in these specific instances:

1. In case of death of the resident.

1. Mom & Dad’s House will not require advance notice to terminate an admission agreement upon the death of a resident and will prevent fees from accruing once all personal property belonging to the deceased resident has been removed.
2. Mom & Dad’s House will not impede the removal of a deceased resident’s personal property, during reasonable hours, by an individual or individuals authorized by the resident or the resident’s responsible person, as identified in the admission agreement or attachment, or by a court-appointed executor or administrator of the decedent’s estate, if applicable.
3. Mom & Dad’s House will refund fees paid in advance covering the time after the resident’s personal property has been removed from the facility to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the deceased resident’s personal property is removed.
4. If fees are assessed while the resident’s belongings remain in the living unit after the resident is deceased, Mom & Dad’s House will provide the deceased resident’s responsible person, or other individual or individuals as identified in the admission agreement or attachment, written notice of the facility’s policies regarding contract termination upon death and refunds within three days of becoming aware of the resident’s death.

2. In the event of resident’s death or in any way vacating of premises, facility will make reasonable efforts to assist resident and/or responsible person with belongings removal. Facility requires all resident personal belongings to be removed within 15 days of the resident's death.
3. As mandated by Health and Safety Code 1569.153(f), if the responsible person is unable or unwilling to claim the property within the fifteen-day period, facility must write the county's Public Administrator. If the Public Administrator does not take possession of resident belongings, Mom & Dad’s House may dispose of resident belongings unless alternative arrangements are made. Facility is not responsible for storing belongings.Signing below acknowledges the law and the facility’s policy about belongings removal.

4. In the event Community Care Licensing orders the immediate relocation of the resident.

51. FIREARMS

To ensure the safety of residents and staff firearms and ammunition are not permitted within any part of Mom & Dad’s House.

Prior to admission, residents will be informed of the prohibition of any firearm or ammunition within any part of the community.

On admission the resident and or responsible party, as appropriate will be asked if any firearms are being brought into the building.

Should a staff member suspect or identify a firearm or ammunition is present in the community, the administrator is to be notified immediately.

If the resident refuses to allow the firearm to be removed or at anytime staff or resident safety is in danger, the police or sheriff will be notified immediately by calling 9-1-1.

52. CONSENT TO PHOTOGRAPH

By initialing below, I hereby authorize this facility to use my image (photo) for identification purposes only to ensure resident safety and well-being. This may include photographing portions of resident’s body to document skin condition. Any photos of this nature will be kept in strictest confidence and not used commercially. Initials _____.

In addition, I hereby authorize Mom & Dad's House to use resident’s image (photo) for possible use in public forms of advertising including but not limited to website, brochures or local advertising. Initials _____ .

53. BEDRAILS AND HOSPITAL BEDS

The Department allows the use of bedrails but under very strict conditions. Thus, the facility must approve all beds equipped with bedrails prior to occupancy, especially “hospital beds,” to ensure compliance with state laws and regulations and facility policies. The State allows “half bedrails,” but only to assist the resident with mobility, i.e. turning, repositioning and transferring. Under state regulations, bedrails require a physician’s order specifically stating for use with mobility and the bedrails must be as close to the head of the bed as possible. Facility requires half rails be no less than 2-3 inches from the head of the bed. Full rails are not allowed unless the resident is admitted onto hospice.

Mom & Dad’s House requires hospital beds provided by hospice companies to be fully electric, to protect staff from back injuries from lifting the bed up and down manually. Hospital beds supplied by hospice companies should be approved by facility.

54. FALLS

There are many factors that can contribute to falls – medication, poor eyesight, illness, poor oxygenation, footwear, resident mobility, aging, etc. Many residents are admitted to residential care homes because of fall risk. Mom & Dad's House provides a high level of care but is unable to provide one-on-one attention. Even under higher supervision residents are at risk of falling. Facility asks that resident rooms not be furnished with throw rugs or extension cords, and any oxygen tubing kept to a manageable length.

55. HIRING MOM & DAD’S HOUSE FOR PERSONAL CARE OUTSIDE MOM & DAD’S FACILITY

Client agrees not to recruit, contract with, or employ any of Mom & Dad's House’s employees, agents, contractors, or subcontractors that provide Services to our residents during the term of the Agreement and for a period of 12 months after the termination of this Agreement. Client agrees that the restrictive covenants contained in this paragraph are fair, reasonable, and necessary for the protection of the legitimate business interests of Mom & Dad's House. The provisions and terms of this Paragraph shall survive the termination of this Agreement. Should the Client recruit a Mom & Dad's House employee, agent, contractor, subcontractor, or subcontractor, Client shall pay Mom & Dad's House $___________.

56. TIPPING OF STAFF AND LOANS

It is Mom & Dad's House’s policy that members of its staff not receive or solicit tips from the residents or individuals visiting the resident, including family members. Please do not give money to the staff, unless cleared by the administrator.

The facility does not allow resident and/or responsible party to loan money to staff or the licensee. Loans create numerous legal entanglements and paperwork for the licensee. It is clearly the policy of the facility to NOT allow loans to be given to anyone affiliate with the facility, especially care staff.

57. MISSING RESIDENTS

Under California Health & Safety Code 1569.317, every residential care facility for the elderly shall develop and comply with an absentee notification plan to address issues that arise when a resident is missing from the facility.

Mom & Dad’s House developed and complies with an absentee notification plan for each client or resident to address issues that arise when a client or resident is missing from the facility. This plan is part of the resident’s written record of care.

If a resident is missing from the facility, the administrator of the facility, or his/ her designee, will do the following:

1. Notify the resident's authorized representative. Check to see if the resident is with the authorized representative and/or the authorized representative knows where the resident is, or might be going.
2. Notify local law enforcement and provide them with the following information:
1. Current Description and photo of the resident
2. What the resident was wearing before leaving the facility
3. Any special medical conditions the resident may have
3. Search the neighborhood to try and locate the resident.
4. When the resident is found, the Administrator will do a new assessment and evaluate the resident to see if it is appropriate to continue to care for the resident in the facility or it is time to look at relocating the resident to a higher level of care.
5. Send an incident report LIC624 to licensing.
6. If the resident will continue to reside in the facility staff will have training to do everything possible to prevent any further elopements.

58. END OF LIFE OPTION ACT

Facility has elected, for reasons of conscience, morality or ethics, to not have its employees participate in activities related to the “end-of-life” act. This includes delivering the prescription for, dispensing, or delivering the prescribed aid-in-dying drug; and being present when the resident takes the aid-in-dying drug prescribed by resident’s attending physician. Any decision made by the qualified individual to obtain and/or take aid-in-dying medication will NOT result in resident eviction or threat of eviction, discrimination, or harassment. Facility will NOT place aidin- dying medication in its centrally stored medication location, and if resident stores the medication in his or her room, resident’s physician must indicate the client is capable of selfstorage of personal medications. Facility does require this medication to be locked in a safe place within the resident’s personal storage space. The resident is NOT required to disclose to any facility personnel the intent to use the aid-in-dying medication, but the enacted law does require a witness to the resident self-administering this medication. Facility staff will not act as a witness due to reasons of conscience, morality and/or ethics. Facility staff does not witness any verbal or written notices presented to a physician about the desire to obtain and/or use aid-in-dying medications.

59. COUNCILS

1. Resident Council:

Residents have the right to organize and participate in a resident council. (H&S 1569.269(a)(27), 1569.157)

Two or more residents admitted into the facility may form a resident council with the assistance of the facility. The council is composed only of residents, but other may be invited to participate in council meetings. A purpose of the resident council is to make recommendations to the administrator on how to improve the quality of daily living and

promote and protect residents’ rights. Any recommendations presented in writing to the administrator will be acted upon in 14 calendar days or less. The council can meet independently with outside persons or staff, and to be informed of the right to participate in the regulatory inspection process. Other provisions of a resident council are posted in this facility.

Attached as an addendum to this Admission Agreement is our policy on Resident and Family Councils (See Attachments # 5 )

_____ I have received a copy of the Rights of Residents Councils.

2. Family Council

When requested by a member of the resident’s family or resident’s representative, facility will allow the formation of a family council and allow the council to meet in the facility during mutually agreed upon hours and in a common meeting room in the facility. A family council is a meeting of family members, friends and others of at least two residents who may confer in private without the presence of facility staff. Facility will assist in the council meeting by posting notices of meetings, and minutes, information or newsletters produced by the council. Facility is unable to write the notices, write the minutes or prepare councilrelated information. Any concerns or recommendations submitted in writing to the administrator by the council will be acted upon within 14 days or less.

60. MOTION DETECTION ALARMS

If the resident gets up throughout the night, it might be a good idea to have a motion censored alarm installed to alert staff that the resident is awake and trying to use the restroom. Mom & Dad’s House supports the use of such items; however, it is the responsibility of the resident’s family to find, purchase and maintain them.

Some of these alarms include:

Floor Alarm Mat - http://www.securesafetysolutions.com/matsets.htm

Chair Alarm

Bed Alarm - Smart Caregiver Wireless and Cordless Weight Sensing Bed Pad – 10” x 30” (Monitor or Alarm Included).

Infrared Motion Sensor - http://smartcaregiver.com/motion-sensor-alarm-systems/

Initial: __________

61. SURVEILLANCE CAMERAS

Facility does not consent to or allow the resident or resident’s representative’s use of hidden or exposed cameras or video equipment, including the concealed or revealed use of recording equipment in resident room or other areas of the facility. It is strictly prohibited under California and Federal privacy laws.

However, facility may use cameras under the following guidance by Department of Social Services:

1. Mom & Dad’s House - Cottage common areas are monitored by surveillance cameras
2. Surveillance cameras are for the only purpose of supporting the supervision of staff.
3. Surveillance cameras do not have an audio component.
4. Recordings of the videos taken by the surveillance cameras will not be maintained in the residents’ records.
5. Surveillance records are stored on an external hard drive that can only be accessed by the administrator.
6. Surveillance Records will be stored for a limited time and then automatically deleted from the system.
7. Access to life videos and records require login information and password. Only the administrator and managing owners will have access to this information.
8. Upon request, those with legal authority, will be allowed to view any saved recordings.
9. Video monitoring equipment and data will be inaccessible to unauthorized persons including staff.
10. Personal Rights:
• - Right to privacy in accommodations: Mom & Dad’s House will NOT install any cameras in private areas of the residence to protect the privacy of our residents.
• - Right to confidentiality of resident records: Surveillance records will not be maintained under the residents records. Only the administrator, managing owners, and those authorized by law will have access to records.
• - Right to have private visits: Surveillance will NOT have an audio component to protect residents privacy in their visits and conversations.
• - Right to privacy when receiving medical treatment: Surveillance cameras will not be installed in any private areas to allow our residents to receive privacy when receiving medical treatments.

62. TERMINATION OF SERVICE AGREEMENT

1. The agreement is automatically terminated by the death of the resident. Because the facility accepts its fees at the first of each month, in the event of the resident’s death, from that date, the resident’s representative would not be liable for any payment as all service fees has been paid. However, if optional services were utilized during the days prior to resident’s death, then resident’s representative would be responsible for these additional charges.
2. Thirty days notice of intent to vacate is required by resident to terminate this agreement.
3. The Department of Social Services has the authority to order resident’s relocation, with proper notification, for any of the following reasons:
1. Resident’s condition cannot be cared for within the limits of the licensee
2. Resident requires inpatient care in a health facility
3. Resident’s mental or physical condition requires immediate transfer to protect my health and safety.

63. MODIFICATION CONDITIONS

Facility may, with a 30-day written notice to resident or responsible person, amend this contract when such an amendment does not involve fees. Resident or responsible person will be asked to sign and date the amendment. In addition, facility will provide resident and/or responsible party with a 30-day written advanced notice of a necessary room change including an emergency or to fill a vacant bed. Resident may agree to waive the 30-day notice and move immediately to a different room.

64. SEVERABILITY

If one provision or paragraph of this agreement shall be invalidated in a legal proceeding, the remaining provisions or paragraphs shall remain in full force and effect.

SIGNATURES

I agree to the terms state in this agreement. Under California Health and Safety Code 1569.887 and Title 22 section 87568(e), the signatures below represents the resident’s or responsible person’s acknowledgement of this agreement’s terms and conditions. I have read and do understand all of the preceding pages. I have received a copy of this agreement and acknowledge that Mom & Dad's House has the original agreement. I agree to all the terms of this agreement.

VOLUNTARY ARBITRATION

Arbitration of Disputes. By signing below, you agree that any and all claims and disputes arising from or related to this Agreement or to your residency, care or services at the Community, whether made against Blue Horizon Homes, LLC d/b/a Mom and Dad's House or it's owners, officers or employees, shall be resolved by submission to neutral, binding arbitration in accordance with the Federal Arbitration Act; except that any claim or dispute involving unlawful detainer proceedings (eviction) or any claims that may be brought in small claims court shall not be subject to arbitration unless both parties agree to arbitrate such proceedings.

Both parties give up their constitutional rights to have any such disputes decided in a court of law before a jury, and instead accept the use of arbitration. The arbitration shall be conducted in the County of Los Angeles, California by a single neutral arbitrator selected as provided for in the California Code of Civil Procedure unless otherwise mutually agreed. In reaching a decision, the arbitrator shall prepare a written decision that includes findings of fact, the reasons underlying the decision, and conclusions of law. Each party shall bear its own costs and fees in connection with the arbitration unless otherwise provided for by statute.

You may withdraw your agreement to arbitrate within thirty (30) days after signing this Agreement by giving written notice of your withdrawal to Blue Horizon Homes, LLC d/b/a Mom and Dad's House .

This arbitration clause binds all parties to this Agreement and their spouses, heirs, representatives, executors, administrators, successors, assigns, managers, and agents as applicable. After termination of this Agreement, this arbitration clause shall remain in effect for the resolution of all claims and disputes that are unresolved as of that date.

In the event that any part of this arbitration clause is determined to be unenforceable, the remaining portions of the clause shall remain valid and shall be enforced by the parties.

By signing below, you warrant that you have had the opportunity to ask questions and have the above paragraphs regarding arbitration of disputes explained to you, that you understand the arbitration agreement's significance, and that you voluntarily agree to be bound by it.

BY SIGNING THIS AGREEMENT THE PARTIES HEREBY WAIVE THEIR RIGHTS TO RESOLVE DISPUTES BY A JURY TRIAL.

ATTACHMENT # 1

LGBT RIGHTS

Health and Safety Code Section 1439.51

RESIDENTIAL CARE FACILITIES FOR THE ELDERLY

Explanation: Health and Safety Code Section 1439.51. Each resident shall have LGBT Rights which include, but are not limited to, the following:

1439.51. (a) Except as provided in subdivision (b), it shall be unlawful for a long-term care facility or facility staff to take any of the following actions wholly or partially on the basis of a person’s actual or perceived sexual orientation, gender identity, gender expression, or human immunodeficiency virus (HIV) status:

(1) Deny admission to a long-term care facility, transfer or refuse to transfer a resident within a facility or to another facility, or discharge or evict a resident from a facility.

(2) Deny a request by residents to share a room.

(3) Where rooms are assigned by gender, assigning, reassigning, or refusing to assign a room to a transgender resident other than in accordance with the transgender resident’s gender identity, unless at the transgender resident’s request.

(4) Prohibit a resident from using, or harass a resident who seeks to use or does use, a restroom available to other persons of the same gender identity, regardless of whether the resident is making a gender transition or appears to be gender-nonconforming. Harassment includes, but is not limited to, requiring a resident to show identity documents in order to gain entrance to a restroom available to other persons of the same gender identity.

(5) Willfully and repeatedly fail to use a resident’s preferred name or pronouns after being clearly informed of the preferred name or pronouns.

(6) Deny a resident the right to wear or be dressed in clothing, accessories, or cosmetics that are permitted for any other resident.

(7) Restrict a resident’s right to associate with other residents or with visitors, including the right to consensual sexual relations, unless the restriction is uniformly applied to all residents in a nondiscriminatory manner. This section does not preclude a facility from banning or restricting sexual relations, as long as the ban or restriction is applied uniformly and in a nondiscriminatory manner.

(8) Deny or restrict medical or non-medical care that is appropriate to a resident’s organs and bodily needs, or provide medical or non-medical care in a manner that, to a similarly situated reasonable person, unduly demeans the resident’s dignity or causes avoidable discomfort.

(b) This section shall not apply to the extent that it is incompatible with any professionally reasonable clinical judgment.

ATTACHMENT # 2

Field Trip Release, Waiver of liability and
Hold Harmless Agreement

This Field Trip Release, Waiver of Liability and Hold Harmless Agreement is entered into by or on behalf of _________________________________. From time to time Blue Horizon Homes, Inc (AKA Mom & Dad's House) offers field trips/activities off its premises for its residents. Participation is always voluntary. Public transportation and/ Uber/Lyft are used to transport residents on these Mom & Dad's House sponsored field trips/activities.

By signing this agreement I acknowledge that the mode of transportation and nature of any particular field trip/activity may expose me to increased risks that may result in my illness, personal injury or death and I understand and accept all such risks. In particular, I understand the risk of injury from falls increases during these field trips/activities. I recognize and acknowledge that certain risks of harm are or may be inherent and that Mom & Dad’s House cannot control all risks. I understand that Mom & Dad’s House is not responsible for any medical expenses associated with any property or personal injury that I may sustain on Mom and Dad's House sponsored field trips/activities.

In consideration of Mom & Dad’s House permitting me to participate in field trips/activities outside Mom & Dad's House and in transporting me and/or coordinating transportation, I release Mom & Dad’s House and its officers, employees, and representatives from any and all liability to myself and my personal representatives, estate, heirs, and assigns for any and all claims, demands and causes of action for any and all loss of personal property, illness or injury, including death, arising out of, resulting from, caused by, occurring during or in any way connected with the field trip/activity, including injuries caused by Mom & Dad’s House officers, employees, and representatives, or any other participant in the field trip/activity that I may sustain while participating in such field trip/activity.

I understand that Mom & Dad’s House does not provide medical insurance for me. I am urged by Mom & Dad’s House, to maintain adequate personal health and accident insurance to cover any personal injury to myself which may be sustained while participating in any field trip/ activity.

I agree to indemnify and hold harmless, waive and covenant not to sue Blue Horizon Homes, LLC (AKA. Mom & Dad’s House) officers, employees, and representatives from liability for the injury or death of any person(s) and damage to property that may result from my own negligent or intentional act or omission while participating in any such field trips/activities. It is my express intent that this Covenant Not to Sue and Agreement to Hold Harmless shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representatives, if I am deceased, and shall be governed by the laws of the State of California.

ATTACHMENT # 2

Field Trip Release, Waiver of liability and
Hold Harmless Agreement

I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND THAT IT IS A RELEASE, WAIVER AND HOLD HARMLESS OF LIABILITY OF ALL CLAIMS FOR ANY INJURY OR DEATH TO MYSELF THAT OCCURS WHILE PARTICIPATING IN ANY MOM & DAD'S HOUSE SPONSORED FIELD TRIP OR OFF PREMISES ACTIVITY AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY MY OWN NEGLIGENT OR INTENTIONAL ACT OR OMISSION.

I have read and agree to the terms and conditions of the Blue Horizon Homes, LLC. Field Trip Release, Waiver of Liability, and Hold Harmless Agreement. I understand this document will be considered effective on the date signed.

I represent and acknowledge by my signature below that I am fully competent to sign this Agreement. I acknowledge that I am signing this Release, Waiver of Liability and Hold Harmless Agreement on my OWN behalf and I agree to be bound by the terms of this Release, Waiver of Liability and Hold Harmless Agreement.

I acknowledge that I am signing this Release, Waiver of Liability and Hold Harmless Agreement on behalf of _______________________________ as his/her agent and/or legal representative. I agree on his/her behalf to be bound by the terms of this Release, Waiver of Liability and Hold Harmless Agreement. I additionally agree to personally hold Blue Horizon Homes, LLC (AKA. Mom & Dad’s House) harmless for injury to _________________________ resulting from his/her participation in any Mom & Dad's House field trip/activity occurring off the facility premises.

ATTACHMENT # 3

THEFT & LOSS POLICY

THIS THEFT AND LOSS POLICY AND PROCEDURE PROGRAM WILL BE REVIEWED BY ALL STAFF, TWICE A YEAR.

The following paragraphs contain information on the policies and procedures for safeguarding resident’s personal property.

INVENTORY

It is the policy of the facility to maintain a current inventory of all personal property identified by residents. Upon admission, all residents will be requested to appropriately label all clothing and personal items. Residents will be asked to keep no more than $______ cash at any time. Residents will be requested to keep fine jewelry and other items of value in a safe deposit box at their banking institution. No items of value will be entrusted to the facility for safekeeping and no cash or other moneys will be entrusted to the facility. All resident personal items must be inventoried unless the resident refuses the inventory and the refusal is documented. The inventory can be written on the State form or on the form on the following page, if desired. When the form is complete, copies will be distributed to and kept by the facility, the resident’s family or responsible party, and the resident. If the resident has any additions to their personal inventory, it is the facility’s policy to update the list and to make sure that the responsible parties obtain the updated copies. Likewise, when the resident loses or removes any items from their personal inventory, they are to notify the facility immediately and the facility will document appropriately. In the event of a resident’s discharge or a resident’s death, the inventory list will be verified and the personal items will be packed. When the items are returned to the resident’s family or responsible party the list will be re-verified and signed in receipt of belongings.

THEFT AND LOSS

The policy of the facility is to document all theft and loss of personal property. When resident notices a personal item are missing they are to notify the staff immediately. The staff will conduct a thorough search for the missing item or items. If the personal belongings cannot be found, an estimate of their value will be assessed. The estimate will be the original purchase price plus or minus any appreciation or depreciation that has occurred. If the theft exceeds $______ or more, a report shall be filed with a Law Enforcement Agency within 36 hours of the theft. All appropriate documentation of the incident will be given to all the responsible parties. The facility will maintain the records on file for a minimum of three (3) years after the theft. All staff will receive in-service training on the importance of returning resident belongings immediately to the residents’ rooms.

ATTACHMENT # 3

THEFT & LOSS POLICY

IDENTIFICATION

It is the facility’s policy to label all of the resident’s personal property for their protection. First, all clothing will be labeled with permanent laundry markers to clearly identify which resident they belong to. Second, all personal belongings that can be marked with permanent pen will be marked in discreet locations. In cases where the item or items cannot be safely labeled with a non-erasable marker an electric pencil will be used to engrave the resident’s name in a discreet place on the items, if the resident agrees.

SECURITY

The facility does not have a safe on the premises to allow for safe keeping of residents’ valuables. They are encouraged to use their own private banking institution to provide this service. The facility policy is to provide all rooms with either a lockable door of which the resident has a key or a lockable cabinet of which the resident also has a key.

NOTIFICATION

It is the policy of the facility to notify interested parties about the loss prevention program and provide them with copies of applicable laws. The facility will post the policy and procedures for safeguarding the residents’ property on the information board in the facility. Upon admission to the facility, the resident and interested parties will be notified verbally and given a copy of the Theft and Loss program. Copies of these procedures and applicable laws are available to anyone upon request.

ATTACHMENT # 4

ATTACHMENT # 4

ATTACHMENT # 5

RIGHTS OF RESIDENT COUNCILS

1. Mom & Dad’s House, at the request of two or more residents, will assist the residents in establishing and maintaining a single resident council at the house. The resident council will be composed of residents of the facility. Family members, resident representatives, advocates, long-term care ombudsman program representatives, facility staff, or others may participate in resident council meetings and activities at the invitation of the resident council.
2. A resident council may, among other things, make recommendations to Mom & Dad’s House administrators to improve the quality of daily living and care in the Mom & Dad’s House and to promote and protect residents’ rights.
3. If a resident council submits written concerns or recommendations, Mom & Dad’s House will respond in writing regarding any action or inaction taken in response to those concerns or recommendations within 14 calendar days.
4. Mom & Dad’s House policies on resident councils will not limit the right of residents to meet independently with outside persons or Mom & Dad’s House personnel.
5. Each resident council member shall be informed by Mom & Dad’s House of his or her right to be interviewed as part of the regulatory inspection process.
6. Mom & Dad’s House will promote resident councils as follows:
1. If a Mom & Dad’s House has a resident council, the Mom & Dad’s House will inform new residents of the existence of the resident council. Mom & Dad’s House will also provide information on the time, place, and dates of resident council meetings and the resident representative to contact regarding involvement in the resident council.
2. If Mom & Dad’s House does not have a resident council, upon admission, Mom & Dad’s House will provide written information on the resident’s right to form a resident council to the resident and the resident representative, as indicated in the admissions agreement.
3. Upon request, and with the permission of the resident council, Mom & Dad’s House will share the name and contact information of the designated representative of the resident council with the long-term care ombudsman program.
4. Mom & Dad’s House will not willfully interfere with the formation, maintenance, or promotion of a resident council, or its participation in the regulatory inspection process. For the purposes of this subdivision, willful interference shall include, but not be limited to, discrimination or retaliation in any way against an individual as a result of his or her participation in a resident council, refusal to publicize resident council meetings or provide appropriate space for either meetings or a bulletin board, or failure to respond to written requests by the resident council in a timely manner.
5. Mom & Dad’s House will post this information in a prominent place at the facility accessible to residents, family members, and resident representatives.